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Medical Management of Rosacea:Role of Proper Skin Care andTreatment Selection

5

DERMATOLOGY NURSING

DERMATOLOGY NURSING/December 2008/Supplement

Rosacea is a chronic disordercharacterized by varying com-binations of central facial ery-thema, telangiectasia, inflam-

matory lesions (papules and/or pus-tules), edema, and flushing, as well asintermittent periods of exacerbationand remission. Associated symptoms

often include stinging, burning, pruri-tus, and scaling (Del Rosso, 2006;Millikan, 2003). Rosacea has beenclassified into several well-definedsubtypes based on morphologic char-acteristics (Del Rosso, 2006). Theseclassifications are designated as sub-types rather than stages. There is nopredictable progression from onesubtype to another, and any givenpatient may present with clinical fea-tures of more than one subtype.Regardless of subtype, the severity of signs and symptoms is variable (DelRosso, 2006).

The pathophysiology of rosacea remains elusive with several patho-physiologic associations described.Vascular and inflammatory compo-nents appear to be operative. Dermalmatrix degradation and chronic alter-ation of superficial cutaneous vascula-ture have been described as featuresof rosacea (Millikan, 2004; Murphy,2004; Yamasaki et al., 2007). Chronic

photodamage (ultraviolet [UV] light

exposure) contributes to the progres-sion of dermal matrix degradation.This is a consequence of the produc-tion of reactive oxygen species andup-regulation of matrix metallopro-tease enzymes which contribute to thedegradation of dermal collagen andelastic tissue (Del Rosso, 2006;

Millikan, 2004; Murphy, 2004).Additionally, high levels of catheli-cidin and serine protease have beendetected in the skin of patients withrosacea as compared to normal skin of subjects without rosacea (Yamasaki et al., 2007). These findings suggest that chronic cutaneous inflammation con-tributes to the pathogenesis of rosacea (Yamasaki et al., 2007).

Genetic factors appear to con-tribute to the intrinsic predispositionof an individual to develop rosacea,and extrinsically, a variety of environ-mental triggers influence the tendencyto flare (Millikan, 2003). Commonlyidentified triggers include sunlight,heat, cold, wind, ambient hot temper-ature, consumption of spicy food,alcohol, and emotional stress.

Epidermal barrier dysfunction,characterized by increased transepi-dermal water loss predominantly in-volving the central facial region, is aninnate component of both inflamma-

tory (papulopustular) and erythema-

James Q. Del Rosso, DO, FAOCD, is Dermatology Residency Director, Valley Hospital Medical Center, Las Vegas, NV.

Rosacea is a common chronic facial dermatosis affecting adults. The pathophysiology appears to be multifactorial; however, epidermal barrier

dysfunction, inflammation, and dermal matrix degradation are components of the disease.Medical management is dependent on clinical presentation, and warrants a three-pronged approach inclusive of patient education, proper skin care, and use of

topical and/or systemic agents.

James Q. Del Rosso

This article and the CNE answer/evaluation form are also available

online at

www.dermatologynursing.net

OBJECTIVESThis continuing nursing educational (CNE) activity is designed for nurs-

es and other health care providers who care for and educate patients andtheir families regarding rosacea. For those wishing to obtain CNE credit, anevaluation follows. After studying the information presented in this article,the nurse will be able to:

1. Discuss the characteristics and pathophysiology of rosacea.

2. Summarize the medical treatment options for rosacea.3. Describe skin care management techniques for rosacea.4. List key points of patient education for rosacea.

Complimentary CNE for this Supple- ment is available on page 15 and at www.dermatologynursing.net



DERMATOLOGY NURSING

DERMATOLOGY NURSING/December 2008/Supplement6

totelangiectatic rosacea (Del Rosso &Baum, 2008; Dirschka, Tronnier, &Folster-Holst, 2004; Draelos, 2004).

Increased loss of water from the epi-dermis increases dryness and fine fis-suring of the skin, and explains thecommonly recognized clinical featureof sensitive facial skin in rosacea. Thesymptoms and signs that are com-monly reported by the patient withrosacea parallel those which havebeen documented at baseline inrosacea studies before initiation of top-ical therapy. This supports the clinicalobservation that signs and symptoms,such as dryness, scaling, stinging,burning, and itching are inherent torosacea, and are reported by approx-imately 30% to 50% of patients (DelRosso & Baum, 2008; Elewski,Fleischer, & Pariser, 2003). Manyexternally applied irritants, whichmay be included in multiple skin careand cosmetic products that are poor-ly selected for individuals withrosacea (non-gentle cleansers, astrin-gents, etc.), can exacerbate signs andsymptoms of the disorder (Del Rosso,

2006).A three-pronged approach isoptimal for managing rosacea inmany patients (Del Rosso & Baum,2008). Patient education provides a more comprehensive understanding of the disease state itself, teachespatients on proper use of skin careproducts and medications, empha-sizes the importance of compliance,and sets realistic patient expectationsregarding the anticipated magnitudeof improvement and the time course

of response. Appropriate skin caremanagement can help repair andmaintain skin barrier integrity, reducesymptoms and signs of the disease,and augment the therapeutic benefit of medication. Although treatment of rosacea is not curative, medical thera-pies can effectively reduce signs andsymptoms of the disease. In patientswith inflammatory rosacea, bothappropriately selected topical and/orsystemic agents can markedly reduceinflammatory lesions, erythema, and

associated symptoms. Importantly, a proper skin care regimen serves toreduce signs and symptoms of rosacea by helping to repair the epi-dermal barrier, and also serves to aug-ment the therapeutic benefits of treat-ment. The dermatology practice will

be most time efficient and outcomeswill be more successful if the nursing staff are integrally involved in educat-ing patients regarding the details of the management plan.

Medical Treatment OptionsCurrently available medical

treatment options for rosacea includeboth topical and systemic agents.Available data show that these agentsare capable of reducing the numberof inflammatory lesions and the inten-

sity of erythema (Del Rosso, 2006;Del Rosso & Baum, 2008).

Topical agents. The three topicaltherapies with an indication forrosacea from the U.S. Food and Drug Administration (FDA) for rosacea aresulfacetamide 10%-sulfur 5% (sulfac-etamide-sulfur), metronidazole, andazelaic acid (15% gel) (Del Rosso &Baum, 2008). Topical antibiotics (clin-damycin, erythromycin) and topicalcalcineurin inhibitors (tacrolimus,pimecrolimus) have been used to

treat rosacea; however, they are not approved for this indication and data supporting their use are limited (DelRosso, 2006; Del Rosso & Baum,2008).

Sulfacetamide-sulfur (1956). Sulfa-cetamide-sulfur is available in a vari-

ety of vehicles including a cleanser,lotion, topical suspension, and cream(with and without sunscreen)(DelRosso, 2006; Del Rosso & Baum,2008). The mechanism of action of sulfacetamide-sulfur is not known.Sulfacetamide-sulfur has been shownto reduce inflammatory lesions andperilesional erythema in patients withinflammatory rosacea and assists inreducing associated facial seborrheicdermatitis (see Figure 1).

Topical metronidazole (1989). First

introduced in 1989 as a 0.75% gel, top-ical metronidazole was the first agent approved by the FDA for treating rosacea. Currently, it is available as a 0.75% gel, lotion, and cream, and a 1% cream and gel (Del Rosso, 2006;Del Rosso & Baum, 2008). The anti-inflammatory mechanism of action of topical metronidazole for rosacea relates at least partially to decreasedrelease of reactive oxygen speciesfrom neutrophils. Topical metronida-zole has been shown in several studies

Sulfacetamide 10%/Sulfur 5%+ SPF 18 Cream for Rosacea

SS with Sunscreens Cream (SPF 18) versus Metronidazole Cream 0.075%

P < .05

Shalita AR et al. Skin Aging. 2003;11(10 suppl):17-22.

% R e d u c t i o n i n L e s i o n C o u n t

50

68

82

74

6866

46

63

40

45

50

55

60

65

70

75

80

85

Week 3 Week 6 Week 9 Week 12

SS wi th Sunsc reens Cream Metro Cream

Figure 1.Sulfacetamide 10%/Sulfur 5% plus SPF 18

Cream for Rosacea



DERMATOLOGY NURSING


to decrease inflammatory lesions andperilesional erythema in patients withinflammatory rosacea (Del Rosso,2004; Del Rosso, 2006; Del Rosso &Baum, 2008; Elewski et al., 2003).

Azelaic acid (2002). Azelaic acid15% is available as an aqueous geland is the most recently FDAapproved topical therapy for rosacea (Del Rosso, 2004; Del Rosso, 2006;Del Rosso & Baum, 2008; Elewski et al., 2003). The mechanism of action

of azelaic acid in rosacea is believedto be anti-inflammatory and anti-oxi-dant, with a reduction in the release of reactive oxygen species from neu-trophils reported (Del Rosso, 2004,2006; Elewski et al., 2003). Althoughthe 15% gel formulation contains a 5% lower concentration of azelaicacid than the 20% cream formulationthat is approved for acne vulgaris, the15% gel formulation providesmarkedly greater percutaneous drug

delivery of the active ingredient (DelRosso & Baum, 2008; Draelos, 2006).Azelaic acid is approved for treating inflammatory lesions and erythema in patients with inflammatoryrosacea, with several studies support-ing its efficacy (Del Rosso, 2004,2006; Draelos, 2006; Elewski et al.,2003; Thiboutot, Thieroff-Ekerdt, &Graupe, 2003) (see Figures 2-5).

Systemic (oral) agents. Anti-in-flammatory dose doxycycline (40

Phase III Pivotal Studies: Percent Changein Inflammatory Lesion Count

Continuous and significant reductions noted

Thiboutot et al. J Am Acad Dermatol . 2003;48:836845.

M e a n

r e d u c t i o n f r o m b

a s e l i n e ,

%

–70

–60

–50

–40

–30

–20

–10

0

Weeks

0 4 8 12 AzA gel (n=333)

Vehicle (n=331)

P <.0001

–42.6%

–61.3%

Figure 2.Phase III Pivotal Studies:

Percent Change in Inflammatory Lesion Count

Phase III Pivotal Studies: Change in ErythemaSeverity Rating

*Decrease of at least 1 point in the erythema rating.Thiboutot et al. J Am Acad Dermatol . 2003;48:836845.

30%

P a t i e n t s i m p r o v e d ,

%

0

10

20

30

40

50

60

Weeks

0 4 8 12

AzA gel (n=333)

Vehicle (n=331)

P =.001

50%

Continuous improvement* with AzA gel

Figure 3.Phase III Pivotal Studies:

Change in Erythema Severity Rating

Phase III Comparative Study: Percent Changein Inflammatory Lesion Count

Elewski et al. Arch Dermatol . 2003;139:1444-1450.

Significantly greater reductions over 15 weeks

–75.7%

–61.3%

M e a n r e d u c t i o n f r o m b

a s e l i n e ,

% –0

–10

–20

–30

–40

–50

–60

–70

–80

Weeks

0 4 8 12 15 AzA gel (n=124)

Metronidazole 0.75%

gel (n=127)

P =.002

Figure 4.Phase III Comparative Study:

Percent Change in Inflammatory Lesion Count

Phase III Comparative Study: Changein Erythema Severity Rating

*Decrease of at least 1 point in the erythema rating.Elewski et al. Arch Dermatol . 2003;139:1444-1450.

Weeks

61%

45%

70

60

50

40

30

20

10

0

AzA gel (n=124)

Metronidazole 0.75%

gel (n=127)

P =.017

0 4 8 12 15

P a t i e n t s i m p r o v e d ,

%

Continuous improvement* with AzA gel over 15 weeks

Figure 5.Phase III Comparative Study:

Change in Erythema Severity Rating



DERMATOLOGY NURSING


mg delayed release capsule formula-tion administered once daily) is theonly oral agent approved by theFDA for treating rosacea (Del Rossoet al., 2007). It has proven effectivein rosacea as doxycycline 100 mg

daily, with a similar onset of thera-peutic action and significantly feweradverse events, especially gastroin-testinal side effects (Del Rosso,Schlessinger, & Werschler, 2008).Unlike oral antibiotic doses of tetra-cycline agents (tetracycline, minocy-cline, doxycycline), anti-inflamma-tory dose doxycycline (administeredonce daily) is not categorized by theFDA as an antibiotic as it exhibitsonly anti-inflammatory activitywithout antibiotic effects (Del Rosso

et al., 2007). Several oral antibioticshave been used off-label for rosacea based on a small collection of stud-ies and widespread anecdotal expe-rience (Pelle, Crawford, & James,2004). The effectiveness of anti-inflammatory dose doxycycline, ororal antibiotics such as tetracyclines,in reducing signs and symptoms of rosacea is believed to be due to theiranti-inflammatory properties (DelRosso & Baum, 2008; Del Rosso et al., 2007).

Skin Care ManagementProper skin care can help repair

and maintain the function of the epi-dermal barrier and can reduce signsand symptoms of the disease (DelRosso, 2004; Del Rosso & Baum,

2008) (see Figure 6). As an integralpart of optimal treatment, the recom-mended total skin care regimen forpatients with rosacea utilizes productscontaining synthetic detergent surfac-tants and optimized admixtures of occlusive and humectant componentsto minimize skin barrier dysfunctionand to reduce skin irritation (DelRosso, 2004; Del Rosso & Baum,2008; Draelos, 2001; Draelos, Green,& Edison, 2006). It is also recommend-ed that all patients with rosacea rou-tinely use a high-SPF (15) product toprotect against UV-light-induced epi-dermal and dermal abnormalities that further worsen rosacea (Del Rosso,2004; Draelos, 2001; Pelle et al., 2004).Cosmetic camouflage may be used toconceal erythema and telangiectases(Draelos, 2001).

Selection of skin cleansers. Soap-based cleansers are not appropriatefor patients with rosacea as they havean alkaline pH and produce more

damage to the skin barrier (Del

Rosso, 2003; Del Rosso & Baum,2008; Draelos, 2000). Synthetic deter-gents (syndets) produce less epider-

mal damage with decreased irritationand dryness, and have a pH morecompatible with natural skin acidity.Gentle foaming face washes and lipid-free cleansers are also appropriate foruse in rosacea patients (Del Rosso,2003; Draelos, 2000).

Selection of moisturizers. Treatment of rosacea requires use of an appropri-ately selected skin care program in-cluding everyday use of moisturizers.Moisturizers incorporating humectant and occlusive agents replenish deplet-ed lipids within the impaired epider-mal barrier and restore its ability toretain moisture (Del Rosso, 2003;Draelos, 2000). Humectants (e.g.,glycerin) attract and hold moisturewithin the epidermis, increasing hy-dration and allowing for enhancedpenetration of topical pharmacologicagents (Del Rosso, 2003; Draelos,2000). Occlusives, such as petrolatumand silicates, minimize desiccation bypreventing cutaneous water loss (Del

Rosso, 2003). The beneficial effect of suitable moisturizers on epidermalbarrier function may result in percepti-ble improvement in signs and symp-toms in patients with rosacea (DelRosso & Baum, 2008; Subramanyan,2004).

Use of photoprotectants. Chronicphotodamage has been suggested as a pathogenetic factor in rosacea (DelRosso, 2004, 2006; Del Rosso &Baum, 2008; Millikan, 2003). It is rec-ommended that patients with rosacea

consistently use a photoprotectant (SPF 15) to avoid the dermal matrixdegradation attributed, at least in part,to UV exposure (Del Rosso, 2004;Del Rosso & Baum, 2008).Recommended photoprotectants arethose with broad-spectrum formula-tions capable of filtering both UVAand UVB wavelengths.

Cosmetic selection. When selecting cosmetic and skin care products,patients with rosacea are advised toavoid potential irritants (Del Rosso &

Skin Care Considerations: Cleansers,Moisturizers, and Sunscreens

• Cleansers

– Remove sebum and environmentaldirt, not intercellular lipids1,2

• Use foaming face washes or lipid-freecleansers

• Wash face gently with fingertips

• Moisturizers

– Combine occlusive agents,preventing evaporation, withhumectant agents that attract water 3,4

• Products used should haveminimal irritation potential

• Sunscreens

– UVA/UVB photoprotection mayprevent worsening of rosacea5

• Use sunblock daily

1. Bikowski J et al. 2007;4:60-63; 2. Bikowski J. Cutis. 2001;68:12-19; 3. Bikowski J. Cutis. 2001;68:3-11;4. Del Rosso JQ. Cutis. 2005:75(suppl 3): 17-21; 5. Murphy G. Cutis. 2004(suppl 3):13-16.

Figure 6.Skin Care Considerations:

Cleansers, Moisturizers, and Sunscreens



DERMATOLOGY NURSING


Baum, 2008; Draelos, 2001). The fol-lowing ingredients are most likely tocause exacerbation of rosacea: alco-

hol, witch hazel, fragrance, menthol,peppermint, and eucalyptus oil(Draelos, 2001).

Patient EducationManaging expectations of pa-

tients with rosacea through disease-state awareness establishes realisticoutcomes and encourages compli-ance with treatment. Patients need tobe informed regarding the chronicityof rosacea and its tendency to waxand wane. Education regarding potential flare factors is also impor-tant. The goals of initial improvement and long-term maintenance areimportant points to be explained topatients with rosacea. Key points onwhich patients will need to be coun-seled follow.

Compliance with topical therapy .Patients need to understand theimportance of continuing topical ther-apy after signs and symptoms of rosacea have resolved in order to

maintain remission and prevent recurrence. After discontinuation of therapy, relapse occurs in one-quarterof patients after 1 month and in two-thirds of patients after 6 months (DelRosso & Baum, 2008).

Avoiding UV exposure . It is impor-tant for patients with rosacea to limit the amount of time spent outdoorsduring maximum sunlight exposure(Del Rosso, 2005; Del Rosso & Baum,2008; Pelle et al., 2004). A moisturiz-ing sun protectant should be used

when outdoors during daylight hours.Avoiding other known triggers . If

patients are unsure of what causestheir rosacea flares, they are encour-aged to maintain a diary to help iden-tify their own individual flare factors,and then to do their best to avoidthem as much as possible.

Use of skin care products and cosmetics recommended by their dermatologist/ professional staff . Patients should avoidsoap-based facial cleansers. Cleanserscontaining synthetic detergents, as

well as foaming face washes and lipid-free cleansers are recommended;moisturizers should also be used reg-

ularly basis (Del Rosso, 2005; DelRosso & Baum, 2008; Subramanyan,2004).

Use of proper skin cleansing tech- nique . Patients should be taught toavoid vigorous scrubbing of the face(Del Rosso & Baum, 2008). Washing should be done gently, with only thefingertips. Water at room temperature(lukewarm) should be used during facial cleansing, as hot or cold tem-perature may trigger a flare of erythe-ma and flushing.

ConclusionRosacea is a common chronic

facial dermatosis affecting adults. Thepathophysiology appears to be multi-factorial; however, epidermal barrierdysfunction, inflammation, and der-mal matrix degradation are compo-nents of the disease. Medical manage-ment is dependent on clinical presen-tation, and warrants a three-prongedapproach inclusive of patient educa-

tion, proper skin care, and use of top-ical and/or systemic agents.A major impediment to proper

patient education about rosacea is thelimited time to provide counseling during a busy day at a dermatologypractice. Nevertheless, patients bothwant and appreciate thorough coun-seling about the disease and its man-agement. Although it is important forthe dermatologist to explain diagnosisand treatment to patients, the nursing staff plays a vital role in patient educa-

tion and is best equipped to explaindetails regarding disease-state funda-mentals, skin care product selectionand use, proper application of med-ications, and importance of compli-ance. Handout materials serve as animportant supplement to verbal edu-cation. Patient education pamphletsare available from the NationalRosacea Society, the AmericanAcademy of Dermatology, and asnon-branded materials provided bypharmaceutical companies.

References

Del Rosso, J.Q. (2003). Understanding skincleansers and moisturizers: The correla-

tion of formulation science with the art of clinical use. Cosmetic Dermatology, 16,19-31.

Del Rosso, J.Q. (2004). Medical treatment of rosacea with emphasis on topical thera-pies. Expert Opinions in Pharmacotherapy,5, 5-13.

Del Rosso, J.Q. (2005). Adjunctive skin carein the management of rosacea:cleansers, moisturizers, and photopro-tectants. Cutis, 75, 17-21.

Del Rosso, J.Q. (2006). Update on rosacea pathogenesis and correlation with med-ical therapeutic agents. Cutis, 78, 97-100.

Del Rosso, J.Q., & Baum, E.W. (2008).Comprehensive medical management of rosacea: An interim study report andliterature review. Journal of Clinical and Aesthetic Dermatology, 1, 20-25.

Del Rosso, J.Q., Schlessinger, J., & Werschler,P. (2008). Comparison of anti-inflam-matory dose doxycycline versus doxy-cycline 100 mg in the treatment of rosacea. Journal of Drugs in Dermatology,7, 573-576.

Del Rosso, J.Q., Webster, G.F., Jackson, M.,Rendon, M., Rich, P., Torok, H., et al.(2007). Two randomized phase III clini-cal trials evaluating anti-inflammatorydose doxycycline (40-mg doxycycline,USP capsules) administered once daily

for treatment of rosacea. Journal of the American Academy of Dermatology, 56, 791-802.

Dirschka, T., Tronnier, H., & Folster-Holst, R.(2004). Epithelial barrier function andatopic diathesis in rosacea and perioraldermatitis. British Journal of Dermatology,150 (6), 1136-1141.

Draelos, Z.D. (2000). Therapeutic moisturiz-ers. Dermatology Clinics, 18, 597-607.

Draelos, Z.D. (2001). Cosmetics in acne androsacea. Seminars in Cutaneous Medicine and Surgery, 20, 209-214.

Draelos, Z.D. (2004). Treating beyond thehistology of rosacea. Cutis, 74 (Suppl. 3),

28-31.Draelos, Z.D. (2006). The rationale foradvancing the formulation of azelaicacid vehicles. Cutis, 77 (Suppl. 2), 7-11.

Draelos, Z.D., Green, B.A., & Edison, B.L.(2006). An evaluation of a polyhydroxyacid skin care regimen in combinationwith azelaic acid 15% gel in rosacea patients. Journal of Cosmetic Dermatology,5, 23-29.

Elewski, B.E., Fleischer, A.B.,& Pariser, D.M.(2003). A comparison of 15% azelaicacid gel and 0.75% metronidazole gel inthe topical treatment of papulopustularrosacea. Archives in Dermatology, 139,1444-1450.

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Rosacea Management – Why ItMatters: Nursing Implications andPatient Education

Rosacea is a chronic inflamma-tory process affecting over 13million people. Althoughrosacea affects mostly light-

skinned females between 30 to 50years of age, it can be seen in men,patients with darker complexions,

and even the pediatric population.Topical and oral pharmacologic treat-ments are effective; however, relapseis common with over 60% of patientsrelapsing within 6 months. Pharma-cologic therapy and managing triggerfactors are essential for controlling rosacea. Nursing education plays a vital role in helping guide patients toeffective, lifelong therapy. Nurses areeducators and patient advocates. Weknow that helping patients under-stand their disease and therapyoptions is essential to better outcomes(Lacz & Schwartz, 2004; Wilkin et al.,2002; Wolf, 2005).

Although the process of rosacea is not completely understood, chronicerythema and flushing often result inedema and telangiectasias. Papulesand pustules form and lead to chron-ic inflammation. It has been proposedthat Demodex mites contribute topapule and pustule formation as wellas inflammation. Although not com-

mon, phymatous rosacea — described

as skin thickening, enlarged follicles,irregular surface, generally involving the nose but may affect the forehead,cheeks, or chin — may be caused bythe profibrotic mediator, Factor XIII,a plasma substance (Dahl, 2001).

Persistent central facial erythema,

sparing the periocular area, for at least 3 months is the sole diagnostic criteri-on for rosacea. Other clinical featuressuch as telangiectasias, papules, pus-tules, ocular erythema, and irritation,and rarely phymas, are supportiveclinical signs (Crawford, Pelle, &

James, 2004).

Differential DiagnosisInflammatory acne, seborrhea,

lupus, dermatomyositis, and topicalsteroid misuse should be consideredwhen evaluating patients withfacial redness (Wolff, Johnson, &Suurmond, 2005).

SubtypesIn 2002, the National Rosacea

Society Expert Committee on theClassification and Staging of Rosacea defined diagnostic criteria and foursubtypes of rosacea: erythematote-langiectactic, papulopustular, phyma-tous, and ocular (Abelson, 1999;

Wilkin et al., 2002). A breakdown of

Michelle L. Barton, MSN, CANP,CPNP, is a Nurse Practitioner, Affiliated Dermatologists of Green Hills, Nashville, TN.

Rosacea is a chronic inflammatory process that affects over 13 million people.Patients with rosacea often feel embarrassed, frustrated, or experience low self-esteem.Patients who understand their diagnosis and treatment options are more likely to have positive outcomes; therefore,education is paramount to quality rosacea care.

Michelle L. Barton

This article and the CNE answer/evaluation form are also available

online at

www.dermatologynursing.net

OBJECTIVES

This continuing nursing educational (CNE) activity is designed for nurs-es and other health care providers who care for and educate patients andtheir families regarding rosacea. For those wishing to obtain CNE credit, anevaluation follows. After studying the information presented in this article,the nurse will be able to:

1. Summarize important points for understanding and managing rosacea.2. List key trigger factors of rosacea.3. Describe the importance of patient education in successful treatment

outcomes.

Complimentary CNE for this Supple- ment is available on page 15 and at www.dermatologynursing.net

DERMATOLOGY NURSING



DERMATOLOGY NURSING


characteristics representative of thosesubtypes follows.

Erythematotelangiectactic subtype

characteristics • Flushing • Persistent central facial erythema • Telangiectasias• Burning or stinging sensation• May be sensitive to topical prod-

ucts• Minimal or no inflammatory le-

sions

Papulopustular subtype characteristics • Persistent central facial erythema • Transient papules or pustules or

both• Edema may or may not be pres-

ent • Telangiectasias may be present

Phymatous subtype characteristics • Irregular surface nodularities• Thickening of the skin• Enlargement of the central face,

nose, and/or forehead, ears, andeyelids

Ocular subtype characteristics • Common in 50% of patients withrosacea

• Foreign body sensation, burning,stinging, dryness, itching, photo-sensitivity, and blurred visioninvolving the eyes

• Blepharitis or conjunctivitis

Understanding and ManagingRosacea

Genetic links. Patients of Celtic,northern European ancestry are most

at risk.Treatment regimens. Oral and topi-

cal medications, combined with con-trolling environmental triggers, diet,stress management, and alternativetreatments are the most effective treat-ment approaches.

Length of therapy – Lifelong. Rosa-cea cannot be cured, but it can be con-trolled effectively. After initiating ther-apy, a followup visit should be sched-uled at 4 weeks to assess effectivenessand patient tolerability of the treat-

ment. After achieving good control,patients should followup every 6months for re-evaluation and ongoing management. During followup visits,nurses can help patients by reinforcing treatment regiments, identifying trig-ger factors, and suggesting alternativebehaviors, and coping skills. Examplesinclude exercising indoors under air-conditioning to avoid heat-related flair-ups, wearing a broad-brimmed hat toprotect from the sun, and using mois-turizers with sunscreen to protect against dryness and sun exposure.

Psychosocial aspects. Teach patients

how to manage stress. Anger, anxiety,frustration, and worry may causerosacea flares (National Rosacea Society, 2001). Nurses can helppatients manage these feelings by edu-cating them about stress management techniques. Examples include deep-breathing exercises, visualization tech-niques, yoga, talk therapy, meditation,and support groups.

Treatment Considerations andNursing Implications

Approaches to effective therapies.Treatment options should be selectedbased on the patients subtype, clinicalfeatures, and patient history and most importantly, patient preference (SeeTable 1). A 2002 National Rosacea Society survey found that 81% of patients with rosacea identified sunexposure as worsening their rosacea,but only 5% of patients with rosacea consistently wore sunscreen (DelRosso, 2005). All patients withrosacea should use a UVA/UVB sun-

screen. Because skin sensitivity tomany topical agents is common,products containing silicone, zincoxide, or titanium dioxide are usuallybetter tolerated (Mackley &Thiboutot, 2005).

Topical agents: First-line therapy. Forpatients with mild-to-moderate ro-sacea, the choice of a topical therapyshould be considered. Topical therapymay be used as both a rescue andmaintenance medication. First-tieragents include azelaic acid, metron-idazole, or sulfacetamide. Second-tieragents include erythromycin and clin-

damycin. These agents are relativelysafe, have fewer side effects comparedto oral therapy, and are aimed at reducing redness and inflammatorylesions. However, topical treatmentsmay take longer to achieve improve-ment (Del Rosso, 2000).

Although not approved by theU.S. Food and Drug Administration,other topical agents have been usedto help manage rosacea. Tacrolimusand pimicrolimus may help reduceinflammation and itching. Tretinoin

can reduce inflammation and rosacea lesions (Mackley & Thiboutot, 2005;Nghiem, Pearson, & Langley, 2002).

Oral therapy. Tetracycline, doxycy-cline, and minocycline are commonlyused as first-line oral therapies to re-duce inflammation, papules, and pus-tules (Del Rosso, 2000). Recommend-ed dosing for these medications istetracycline 250 mg to 500 mg QD-BID; doxycycline 50 mg to 100 mg QD-BID; and subantimicrobial doxy-cycline 20 mg BID or 40 mg QD.

Table 1.Selection of Theapy (Topical/Oral)

Topical Oral

Monotherapy for mild-to-moderaterosacea

Slower onset than oralFewer safety/tolerability issuesEffective for maintenance of remission

Severe cases, ocular rosaceaMore rapid onsetAdverse eventsConcerns re: antibiotic resistance from

long-term useLower dose to maintain remission

Source: Del Rosso, 2002.



DERMATOLOGY NURSING


Photosensitivity with doxycy-cline use, and vertigo, hyperpigmen-tation, and lupus-like syndrome with

minocyline use should be consideredwhen choosing therapy. Subanti-microbial doxycycline (Periostat ®) (40mg a day) has the benefit of fewer sideeffects, less antibiotic resistance, andis helpful in reducing inflammationand lesions (Mackley & Thiboutot,2005). Tetracyclines should not beused in patients who are pregnant. Inpatients who cannot tolerate or areallergic to tetracyclines, erythromy-cin, clarithromycin, azithromycin,and metronidazole are effectivechoices.

Laser therapy. Blood vessel forma-tion is not treatable with topical ororal therapies. However, laser thera-py is very effective to reduce bothredness and blood vessels (Bikowski,2003; Mackley & Thiboutot, 2005;Wolf, 2005).

Homeopathic/AlternativeTreatments

Patients are increasingly looking

for “natural” treatments for rosacea.Anti-inflammatory diets, vitamins,creams with natural ingredients, andidentifying food intolerances are someexamples. Unfortunately, clinical tri-als for these treatments are limited.Patients should be informed of thisand told that some natural therapiesmay have adverse side effects, espe-cially in combination with prescrip-tion medications. That said, here aresome suggestions that may be helpful:• Chrysanthellum indicum cream

– reduces redness• Green tea – reduces red bumps

and pustules• Niacinamide – improves skin

barrier and reduces redness; canbe used as a cream or taken oral-ly

• Licorice cream – improves red-ness

• Aloe – reduces irritation• Chamomile – reduces inflamma-

tionDiet and nutritional therapies

Figure 1.Rosacea Flare Factors

Rosacea Flare Factors

HEAT

Inside (eg, exercise,

hot baths, overdressing)

Outside (eg, radiant

heat)

Hot food/beverages

EXERTION

Exercise, chronic cough,

lifting

EMOTIONS

Anger, stress

Embarassment

WEATHER

Hot, cold, strong winds

Spring season

FOOD

Cayenne pepper

Hot coffee / tea

Chocolate

Tomatoes

Citrus fruits

Blackpepper

Cheese

Cured meats

ALCOHOL

Red wine

Liquor

Beer

TOPICAL PRODUCTS

Astringents

Irritants

Some cosmetics

DISEASE

Carcinoid syndrome

Mastocytosis, tumors

Migraine headaches

Hot flashes

DRUGS

Vasodilators, nicotinic

acid, calcium channel

blockers, cholinergic

agents, cyclosporin A,

opiates, tamoxifen,

erectile disfunction drugs

Survey of 1,066 rosacea patients by National Rosacea Society, 1999.

may also be helpful. Encouragepatients to keep a diary to help eluci-date foods that worsen rosacea. Foodsthat are known to cause inflammationinclude caffeine, alcoholic beverages,“fast foods,” high-fat meats, processedfoods, high-sugar foods, tomatoes,candy (except dark chocolate), glutenadditives, and refined carbohydrates.

B vitamins, ginger, tumeric, omega 3fatty acids, and olive oil are just a fewof the anti-inflammatory diet andnutritional examples patients canchoose from to control and improveinflammation (National Center forComplementary and AlternativeMedicine, 2008; Wong, 2007).

Managing Trigger FactorsThere are many rosacea trigger

factors that affect patients in varying degrees (see Figure 1). Managing rosacea triggers is key for improving patients’ quality of life. Dermatologynurses are vital in providing the prop-er patient education necessary toachieve that goal. Strategies for manag-ing trigger factors follow.

Managing trigger factors • Avoid sun exposure, heat, and

humidity. Use fans and facialwater spritzers.

• Avoid saunas, hot tubs, and hot water.

• Carry a small battery-operated fan

or water spritzer when traveling.• Use UVA/UVB sunscreen.• Cover the face on windy or cold

days.• Moisturize daily and more often

in dry climates and cold weather.• Control/manage stress with low-

intensity exercise, yoga, deepbreathing, meditation.

• Employ strategies to stay healthy:maintain a healthy diet and avoidinflammatory foods, get a goodnight’s sleep, practice preventativecare – see your primary careprovider annually, keep bloodpressure under control, managemenopause hot flashes, get yourflu shot, stop smoking (anotherpro-inflammatory behavior).

• Avoid food and beverage triggers,such as caffeine (try decaf coffeeor fruit teas), chili powder (substi-tute cumin), and curry powder(use tumeric).

• Cleanse the face morning andevening with mild, non-fragrant products (such as Purpose® orCeraVe®).

• Avoid harsh cleansing with washcloths, sponges, astringents, andtoners, which may irritate the skinand cause redness and inflamma-tion.

• Use make-up suited to skin type.

For example:



DERMATOLOGY NURSING


* For oily skin, try Neutrogena Skin Clearing oil-free make-up.

* For normal skin, try Neutro-gena Healthy Glow SPF 30make-up.

* For dry skin, try L’Oreal IdealBalance Foundation.

* To camouflage, try Derma-blend or Covermark (greentinted make-up is a good con-cealer for redness and lesions)(National Rosacea Society,2008a, 2008b).

The Importance of Patient TeachingA patient survey conducted in

2000 by the National Rosacea Societyshowed that 75% of rosacea patientsexperienced low self-esteem, 70%described feeling embarrassed, 69%said they were frustrated, and 56% felt robbed of pleasure and happiness(National Rosacea Society, 2000).

With effective therapy, 70% of patients with rosacea reported im-proved well-being, while 60% expe-rienced improved professional inter-actions, and 57% related an im-proved social life (National Rosacea Society, 2000).

The Finacea Patient Survey

(Intendis, 2007) reported that 77% of

patients said that learning about lifestyle changes helped identify theirtrigger factors. Over 60% of patientssaid that learning about their rosacea helped them manage their expecta-tions of treatment. Eighty-seven per-cent of patients said they were morecompliant with their therapy afterlearning about rosacea. The majorityof patients also chose and used appro-priate skin care products after learning about rosacea. With effective therapy,over 78% of patients surveyed saidthey felt more confident and self-assured (see Figures 2-4).

The practice of nursing includes

Figure 2.Education Resource Survey: Appearance

Education Resource Survey

Overall, do you feel better about your appearance since

using rosacea treatment regularly?

Always

Most of the time

Often

Sometimes

Not at all

44.8%

24.1%

10.3%

13.8%

6.9%

Figure 3.Education Resource Survey: Social Situations


Do you feel more confident or self-assured in social

situations, given an improved appearance?

Yes

No 21.8%

78.2%

Figure 4.Education Resource Survey: Education Sources


What have you learned most about from educational

sources of information?

Common trigger factors

“Rosacea-friendly”skin care products

Daily skin care routine

Chronic nature

of rosacea

67.4%

55.8%

44.2%

47.7%

Patient Education Resources for Rosacea

• The National Rosacea Society

– www.rosacea.org

– 1-800-NO-BLUSH

• Dermatology Nurses Association

– www.dnanurse.org

• American Academy of Dermatology

– www.aad.org

• Rosacea Infocenter

– www.rosaceainfocenter.com

• RosaceaNet

– www.skincarephysicians.com/rosaceanet

Figure 5.Patient Education Resources for Rosacea



DERMATOLOGY NURSING

educating our patients. We can defineit as nurturing, enlightening, coach-ing, directing, and informing, but whyis it important? Why does it matter?(see Table 2.)

It matters because there is somuch information available to pa-tients. A Google search of rosacea gives 3,790,000 results. Dermatologynurses must be able to help patientsnavigate through the overwhelming

data. We must be able to give accu-rate and current information to helppatients understand and manage theirhealth concerns, and provide avenuesfor patient support (see Figure 5). Weoften have little time to spend withpatients, so every minute is important and must be used efficiently andeffectively.

Because patients with rosacea often feel embarrassed, frustrated, orexperience low self-esteem, educationis paramount to quality care. Theirpersonal and professional lives areaffected by their disease. Patients whounderstand their diagnosis and treat-ment options are more likely to havepositive outcomes. And that’s whynurses are essential in helping patients with rosacea reach better out-comes by understanding and manag-ing this lifelong disease process.

References

Abelson, M. (1999). An ophthalmologist’sview of ocular rosacea. Skin & Aging,

32 , 50-54.

Bikowski, J. (2003). Subantimicrobial dosedoxycycline for acne and rosacea.SKINmed, 2 , 234-245.

Crawford, G., Pelle, M., & James, W. (2004).Rosacea: 1. Etiology, pathogenesis, andsubtype classification. Journal of the American Academy of Dermatology, 51,327-341.

Dahl, M. (2001). Pathogenesis of rosacea.Advances in Dermatology, 17 , 29-45.

Del Rosso, J.Q. (2000). Systemic therapy forrosacea: Focus on oral antibiotic thera-py and safety. Cutis, 66 (4, Suppl.), 7-13.

Del Rosso, J.Q. (2002). A status report onthe management of rosacea: Focus ontopical therapies. Cutis, 20 (5), 271-275.

Del Rosso, J.Q. (2005). Adjunctive skin carein the management of rosacea:Cleansers, moisturizers, and photopro-tectants. Cutis, 75 (Suppl. 3), 17-21.

Intendis. (2007). Finacea patient survey [unpublished data]. Berlin, Germany.

Lacz, N.L., & Schwartz, R.A. (2004). Rosa-cea in the pediatric population. Cutis,74 (2), 99-103.

Mackley, C., & Thiboutot, D. (2005). Diag-nosing and managing the patient withrosacea. Cutis, 75 , 25-29.

National Center for Complementary andAlternative Medicine. (2008). Herbs at a

glance: Horse c hestnut . Retrieved July 30,2008, from http://www.nccam.nih.gov/health/horsechestnut

National Rosacea Society. (2000). Survey shows rosacea disrupts work for patients with severe symptoms. Retrieved August 11, 2008, from http://www.rosacea.org/rr/2000/fall/article_3.php

National Rosacea Society. (2001). Stress control cuts rosacea symptoms. RetrievedAugust 11, 2008, from http://www.rosacea.org/rr/2001/summer/article_ 3.php

National Rosacea Society. (2008a). Rosacea

triggers. Retrieved October 28, 2008,

from http://www.rosacea.org/patients/materials/triggersindex.php

National Rosacea Society. (2008b). Coping

with rosacea. Retrieved October 28,2008, from http://www.rosacea.org/patients/materials/coping/intro.php

Nghiem, P., Pearson, G., & Langley, R.(2002). Tacrolimus and pimecrolimus:From clever prokaryotes to inhibiting calcineurin and treating atopic der-matitis. Journal of the American Academy of Dermatology, 46 , 228-241.

Wilkin, J., Dahl, M., Detmar, M., Drake, L.,Feinstein, A., Odom, R., et al. (2002).Standard classification of rosacea:Report of the National Rosacea SocietyExpert Committee on the Classifi-cation and Staging of Rosacea. Journal of the American Academy of Dermatology,

46 (4), 584-587.Wolf, J. (2005). Present and future rosacea

therapy. Cutis, 75 , 4-7.Wolff, K., Johnson, R., & Suurmond, D.

(Eds.). (2005). Rosacea. In Fitzpatrick’s color atlas and synopsis of clinical dermatology (5th ed., pp. 8-11). New York:McGraw-Hill.

Wong, C. (2007). Alternative medicine: Natural treatments for rosacea. Retrieved July 29,2008, from http://altmedicine.about.com/cs/treatments/a/Rosacea.htm

• Often genetic• Lifelong treatment/management• Treatment counseling should include:

– Helping patients manage environmental and emotional factors– Educating patients about their treatment regimen and guiding their choice for

therapy– Teaching essential skin care – mild cleansers, daily moisturizers, sunscreen– Providing resource material/rosacea handouts/medication instructions– Encouraging regular followup

- re-evaluate and adjust treatment regiment based on patient historychanges, response to therapy, and improving outcome and compliance

- reinforce treatment/management strategies, educate patient on newtherapies.

Table 2.Rosacea Patient Counseling Summary

Millikan, L. (2003). The proposed inflamma-tory pathophysiology of rosacea:Implications for treatment. SKINmed: Dermatology for the Clinician, 2, 43-47.

Millikan, L.E. (2004). Rosacea as an inflam-matory disorder: A unifying theory?Cutis, 73 (Suppl. 1), 5-8.

Murphy, G. (2004). Ultraviolet light androsacea. Cutis, 74 (Suppl. 3), 13-16.

Pelle, M.T., Crawford, G.H., & James, W.D.(2004). Rosacea II: Therapy. Journal of the American Academy of Dermatology, 51,

449-512.Subramanyan, K. (2004). Role of mild cleansing in the management of patient skin.Dermatologic Therapy, 17 (Suppl. 1), 26-34.

Thiboutot, D., Thieroff-Ekerdt, R., & Graupe,K. (2003). Efficacy and safety of azelaicacid 15% gel as a new treatment forpapulopustular rosacea: Results fromtwo vehicle-controlled, randomizedphase III studies. Journal of the American Academy of Dermatology, 48, 836-845.

Yamasaki, K., Di Nardo, A., Bardan, A.,Murakami, M., Ohtake, T., Coda, A., et al. (2007). Increased serine proteaseactivity and cathelicidin promotes skininflammation in rosacea. Nature Medicine, 13 (8), 975-980.

Medical Management of

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